Airway management in neonates and infants – ESAIC and BJA joint guidelines: Part 1
Mary Lyn Stein, MD, FAAP and James M. Peyton MBChB, MRCP, FRCA
Nothing is more fundamental in our role as pediatric anesthesiologists as our expertise in airway management in general, and in neonates and infants, in particular. Dr. Francis Veyckemans alerted me to this article1,2 which is written by a who’s who of pediatric airway experts and was published jointly by the European J Anaesthesiology and the British J of Anaesthesiology. I asked Drs. Mary Lyn Stein and Jamie Peyton of the Boston Children's Hospital to review it for us. Jamie is a frequent contributor to the PAAD and was one of the authors of the paper. Finally, because of its length and my desire to keep PAADs to 5 to 6 minute reads, I’ve split the discussion into 2 parts. Myron Yaster MD
Original article
Disma N, Asai T, Cools E, Cronin A, Engelhardt T, Fiadjoe J, Fuchs A, Garcia-Marcinkiewicz A, Habre W, Heath C, Johansen M, Kaufmann J, Kleine-Brueggeney M, Kovatsis PG, Kranke P, Lusardi AC, Matava C, Peyton J, Riva T, Romero CS, von Ungern-Sternberg B, Veyckemans F, Afshari A; and airway guidelines groups of the European Society of Anaesthesiology and Intensive Care (ESAIC) and the British Journal of Anaesthesia (BJA). Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines. Eur J Anaesthesiol. 2024 Jan 1;41(1):3-23. doi: 10.1097/EJA.0000000000001928. Epub 2023 Dec 13. PMID: 38018248; PMCID: PMC10720842.
Disma N, Asai T, Cools E, Cronin A, Engelhardt T, Fiadjoe J, Fuchs A, Garcia-Marcinkiewicz A, Habre W, Heath C, Johansen M, Kaufmann J, Kleine-Brueggeney M, Kovatsis PG, Kranke P, Lusardi AC, Matava C, Peyton J, Riva T, Romero CS, von Ungern-Sternberg B, Veyckemans F, Afshari A; airway guidelines groups of the European Society of Anaesthesiology and Intensive Care (ESAIC) and the British Journal of Anaesthesia (BJA). Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines. Br J Anaesth. 2024 Jan;132(1):124-144. doi: 10.1016/j.bja.2023.08.040. Epub 2023 Nov 29. PMID: 38065762.
Today we’ll review new guidelines for airway management in neonates and infants which were commissioned and published jointly by the European Society of Anaesthesiology and the British Journal of Anaesthesia. Readers of the PAAD likely need no reminder that there is a high incidence of critical events during airway management in neonates and infants. The authors of these new guidelines have been instrumental in generating and publicizing data about the critical nature of pediatric airway management3-5 and now have turned their attention to developing evidence based guidelines for safe and effective airway management in neonates and children. They ask several relevant PICO (population, intervention comparison, outcomes) questions and provide recommendations based on their structured literature review and GRADE methodology. This is the most comprehensive review of data on neonatal and infant airway management from all specialties to date. There is much that will seem familiar to readers of the PAAD (and we’ve linked to prior PAADs that take a deeper dive on some of these topics) and a few recommendations that mark a transition in norms of care including recommendations against routine awake intubations of neonates, for use neuromuscular blockade when spontaneous respiration is not necessary, and for use of standard blade video laryngoscopy as the first choice for intubation.
It’s important that we recognize that there is limited high quality data to guide clinicians and the task force -- none of the recommendations received an A “high” GRADE rating for quality. It’s also important to note what these guidelines are not. The guidelines are focused on intraoperative anesthesia settings and are not explicitly designed for use in the NICU, PICU, or emergency departments. Although we believe that the principles outlined here apply across settings, the authors propose, and we agree, that a universal algorithm should be developed in collaboration with pediatric specialties undertaking airway management in neonates and infants across disciplines. Importantly, these are not a new standard of care. The authors clearly state as much, and given the wide variety of resource settings in which infants and neonates receive care, it will be important that the guidelines are locally adapted to best serve patients.
The guidelines also include an infographic and difficult airway algorithm modified from the recent ASA difficult airway algorithm (https://ronlitman.substack.com/p/asa-difficult-airway-new-guidelines). In our opinion, the strength of the guidelines is in their insightful review and synthesis of the literature – which is complex and does not necessarily lend itself to simple diagrams and cognitive aids.
We think the full guidelines are worthwhile reading – for today’s PAAD we’ve highlighted the task force’s top 10 recommendations annotated with our thoughts and comments. We’ve also provided a table describing the GRADE system and the applicable recommendations below. We’re interested in what you think, whether you’ve already adopted any of these recommendations, and whether any will change your practice? Please write to Myron and let us know!
10 key recommendations
1 – Use medical history and physical examination to predict difficult airway management (1C Strong recommendation, low quality evidence)
Not a lot to say about this one – yes we should use history and physical to evaluate all our patients and predict difficult airway management. The subtext here is that despite many efforts to identify something (anything!) better than history and physical we don’t have compelling evidence to support it. There are some physical features that have been associated with difficulty in several retrospective studies including micro-, retro-, or prognathia, limited mouth opening, facial asymmetry, fixed cervical spine, cleft lip and palate, and oral and neck masses. In short, there’s nothing better than a good history and physical exam – or as Myron pointed out asking a good friend (https://ronlitman.substack.com/p/difficult-or-impossible-face-mask) (From Jamie: This shows how we tried to be fully comprehensive in our analysis and recommendations. It is common sense, and it seemed to be pointless trying to research it given the dearth of evidence, But it needed to be included and was a good place to start)
2 – Ensure adequate level of sedation or general anesthesia during airway management (1B Strong recommendation, medium quality of evidence)
Although it may seem obvious on first glance, this one starts to get a little more interesting – remember these recommendations are for anesthesiologists in the operating room, but still, they highlight a move away from routine awake intubation of neonates. The task force reviewed 7 RCTs and 12 observational studies which were limited by the heterogeneity of medication regimens and variable reporting of adverse events. They concluded that there was no evidence of an increase in the number of adverse events related to the use of sedative of general anesthetics medications and that compared with no sedation or anesthesia, anesthesia increased the success rate of intubation on the first attempt and reduced the number of attempts and incidence of complications!
3 – Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1C Strong recommendation, low quality of evidence)
Okay, now we’re really going to raise some eyebrows. Many of us were trained to use neuromuscular blocking agents only when necessary, but in recent years, that teaching has been flipped on its head – use neuromuscular blocking agents unless there is a compelling reason not to (https://ronlitman.substack.com/p/difficult-or-impossible-face-mask) ! The task force reviewed 3 RCTs and 2 observational studies. It’s important to note that many of the studies compare neuromuscular blockade with anesthetic induction techniques that induce apnea without guarantee of the best intubating conditions and with the sequalae of higher dose anesthetic agents. They concluded that neuromuscular blocking agents improve the quality of intubation conditions, decrease the median number of intubation attempts, and reduce the incidence of complications such as laryngospasm. Does this mean that we should paralyze every baby every time? No, but if we choose not to paralyze, we should have a reason beyond just usual practice. Further, a lot of the studies looking at not using NMB actually use apnea inducing techniques (high dose opiate, propofol, servo combos) without the guarantee of achieving the best intubating conditions, and with the added issues of complications relating to high doses of these drugs.
4 – Use a video laryngoscope with an age adapted standard blade as first choice for tracheal intubation (1B Strong recommendation, medium quality of evidence)
Okay this is the one that we’re predicting will inspire the most debate - standard blade video laryngoscope as the first choice for tracheal intubation of ALL neonates and infants. We should note the PAAD has been advocating that VL should be standard of care for neonates and infants since the VISI trial was published (https://ronlitman.substack.com/p/friday-february-19-2021)! There are now multiple randomized control trials including two large multicenter trials demonstrating improved first attempt success rates for video laryngoscopy compared with direct laryngoscopy in infants and at least one showing improved success when an instructor could view the video screen and provide guidance during intubation. Does this mean that direct laryngoscopy is terrible? No, of course not – just like GPS didn’t make maps terrible. In fact, video laryngoscopy can make teaching direct laryngoscopy better (perhaps a topic for a future PAAD of its own). But there is good evidence to support the task force’s recommendation and we’ve adopted video laryngoscopy as our routine for neonates and infants <6.5kg (MLS). I (JMP) would also add in my eternal caveat that with these systems VL and DL are not mutually exclusive and it is easy to perform DL with a video-enabled scope, intubate if there is a view, adjust as needed if there isn’t with guided instruction or switch to indirect laryngoscopy. Helps to limit laryngoscopy attempts as there are 3 methods of intubation in one laryngoscopy!
Do you routinely use video laryngoscopy for neonates and infants now? Will this change your practice? Why not? What are the barriers?
Part 2 will appear tomorrow.
Please send your thoughts and comments and Myron will publish in a Friday Reader response.